Commentary on "C-Reactive Protein for the Diagnosis of Late-Onset Infections in Newborn Infants".
Commentary on "C-Reactive Protein for the Diagnosis of Late-Onset Infections in Newborn Infants".
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作者：
Pammi M;Shah PS
迟发性感染是新生儿医院护理中最常见的严重并发症。由于通过微生物培养确认诊断通常需要24至48小时，因此作为初步调查的一部分测量的炎症标志物C反应蛋白（CRP）的血清水平被用作快速检测，以指导疑似迟发性感染婴儿的管理。探讨血清C反应蛋白检测对新生儿迟发性感染的诊断准确性。我们检索了电子数据库（截至2017年9月的MEDLINE、Embase和Science Citation Index）、会议记录、既往综述和检索文章的参考文献列表。我们纳入了队列和横断面研究，评估血清CRP水平检测新生儿迟发性感染（出生后72小时以上发生）的诊断准确性。两位综述作者独立评估了入选资格，评价了纳入研究的方法学质量，并提取数据，使用分层汇总受试者工作特征（SROC）模型估计诊断准确性。我们通过检查研究估计值的变异性和敏感性和特异性森林图中95%置信区间（CI）的重叠来评估异质性。检索确定了20项研究（1615名婴儿）。大多数是自20世纪90年代末以来在高收入或中等收入国家的新生儿病房进行的小型、单中心、前瞻性队列研究。纳入研究的偏倚风险通常较低，对索引和参考试验进行了独立评估。大多数研究使用预先设定的血清CRP阈值水平作为"阳性"指数试验的定义（典型的临界水平为5 mg/L至10 mg/L），并将血液中的病原微生物培养物作为参考标准。在中位特异性（0.74）时，灵敏度为0.62（95% CI 0.50至0.73）。异源性在森林样地中是明显的，但不可能按胎龄、感染类型或感染微生物类型进行亚组或荟萃回归分析。研究是否使用预定义阈值以及研究是否使用5 mg/L至10 mg/L之间的标准阈值的协变量无统计学显著性。对疑似迟发性感染的婴儿进行初始评估时的血清CRP水平不太可能被认为足够准确，以帮助早期诊断或选择婴儿进行进一步的调查或抗菌治疗或其他干预措施。
Late-onset infection is the most common serious complication associated with hospital care for newborn infants. Because confirming the diagnosis by microbiological culture typically takes 24 to 48 hours, the serum level of the inflammatory marker C-reactive protein (CRP) measured as part of the initial investigation is used as an adjunctive rapid test to guide management in infants with suspected late-onset infection. To determine the diagnostic accuracy of serum CRP measurement in detecting late-onset infection in newborn infants. We searched electronic databases (MEDLINE, Embase, and Science Citation Index to September 2017), conference proceedings, previous reviews, and the reference lists of retrieved articles. We included cohort and cross-sectional studies evaluating the diagnostic accuracy of serum CRP levels for the detection of late-onset infection (occurring more than 72 hours after birth) in newborn infants. Two review authors independently assessed eligibility for inclusion, evaluated the methodological quality of included studies, and extracted data to estimate diagnostic accuracy using hierarchical summary receiver operating characteristic (SROC) models. We assessed heterogeneity by examining variability of study estimates and overlap of the 95% confidence interval (CI) in forest plots of sensitivity and specificity. The search identified 20 studies (1615 infants). Most were small, single-centre, prospective cohort studies conducted in neonatal units in high- or middle-income countries since the late 1990s. Risk of bias in the included studies was generally low with independent assessment of index and reference tests. Most studies used a prespecified serum CRP threshold level as the definition of a ‘positive’ index test (typical cut-off level between 5 mg/L and 10 mg/L) and the culture of a pathogenic micro-organism from blood as the reference standard. At median specificity (0.74), sensitivity was 0.62 (95% CI 0.50 to 0.73). Heterogeneity was evident in the forest plots, but it was not possible to conduct subgroup or meta-regression analyses by gestational ages, types of infection, or types of infecting micro-organism. Covariates for whether studies used a predefined threshold or not, and whether studies used a standard threshold of between 5 mg/L and 10 mg/L, were not statistically significant. The serum CRP level at initial evaluation of an infant with suspected late-onset infection is unlikely to be considered sufficiently accurate to aid early diagnosis or select infants to undergo further investigation or treatment with antimicrobial therapy or other interventions.
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